Get the free Workers' Compensation Self-Insurance Application for 2017

Renewal Date: Montana Department of Labor & Industry Employment Relations Division, Workers\' Compensation Regulation Bureau P.O. Box 8011 Helena, Montana 59604 Phone: (406) 4441555 Fax: (406) 4447710 Email:

How to fill out workers compensation self-insurance application

How to fill out a workers compensation self-insurance application:

1. Start by carefully reading the instructions provided with the application. Familiarize yourself with the specific requirements and any supporting documentation that may be needed.
2. Gather all the necessary information and documentation before beginning the application process. This may include details about your company's structure, ownership, financial statements, and previous workers compensation coverage.
3. Begin by filling out the basic information section of the application, which typically includes your company's name, address, and contact details. Ensure accuracy and double-check for any errors before proceeding.
4. Move on to the section that requires you to provide information about your company's structure and ownership. This may involve disclosing details about the shareholders, board members, and any subsidiaries or affiliated companies.
5. Next, complete the financial section of the application. This typically requires providing information about your company's financial stability and ability to cover potential workers compensation claims. Be prepared to submit audited financial statements, tax return records, and any other relevant financial documentation.
6. Depending on the jurisdiction, you may need to provide information about your company's safety policies, loss prevention programs, or risk management practices. This section highlights the steps your company has taken to ensure a safe working environment for your employees.
7. Review the application thoroughly and make sure all the required fields are complete. Check for any missing information or errors, and make corrections as necessary.
8. Before submitting the application, consider having it reviewed by a legal professional or an insurance specialist to ensure completeness and accuracy.

Who needs workers compensation self-insurance application?

1. Companies opting for self-insurance: Businesses that choose to self-insure their workers' compensation coverage need to fill out a self-insurance application. Self-insurance allows companies to cover their own employees' work-related injuries and illnesses rather than purchasing a policy from an insurance carrier.
2. Large corporations: Larger corporations with sufficient financial stability and adequate resources often consider self-insurance as a viable option. This allows them to have more control over their workers' compensation program and potentially reduce costs.
3. State and local governments: Government entities may choose to self-insure their workers' compensation coverage. It allows them to manage the cost of claims and tailor the program to their specific needs.
4. Professional employer organizations (PEOs): PEOs, which provide HR and other employment-related services to small and mid-sized businesses, may also need to fill out a workers' compensation self-insurance application. This is because they assume certain employment responsibilities for their client companies, including workers' compensation coverage.

Note: The need for workers' compensation self-insurance application may vary depending on the jurisdiction and specific state laws. It is important to consult with the appropriate regulatory authorities or seek professional advice to determine the requirements applicable to your situation.

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What is workers compensation self-insurance application?

Workers compensation self-insurance application is a formal request submitted by an employer to be approved to self-insure for workers compensation benefits.

Who is required to file workers compensation self-insurance application?

Employers who wish to self-insure for workers compensation benefits are required to file the workers compensation self-insurance application.

How to fill out workers compensation self-insurance application?

Employers need to provide detailed information about their financial stability, safety programs, claim management procedures, and other relevant information in the workers compensation self-insurance application.

What is the purpose of workers compensation self-insurance application?

The purpose of workers compensation self-insurance application is to demonstrate the ability of the employer to independently cover the costs of workers compensation benefits for their employees.

What information must be reported on workers compensation self-insurance application?

Employers must report information such as financial statements, safety programs, claim handling procedures, and reinsurance arrangements on the workers compensation self-insurance application.